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63:, <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601'E. HAZEL ION AVE., STOCKTON, CA j <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete in Triplicate) <br /> h. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health DistrictQJ I, <br /> Job Address _ I u Q I �- City of Size PM <br /> �(i�-t` 1 j� �ilGt 7 <br /> Owner's Name - Address r Phone <br /> License No. Phone <br /> Contractor <br /> Address �i' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ElDESTRUCTIO <br /> Ner <br /> PUMP INSTALLATION D SYSTEM REPAIR C1OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD. PROP. LINE ' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ Industrial F1Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I� � <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> F Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth j Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> i available within 200 feet.) <br /> F <br /> Installation will serve: Residence'—! Commercial_ Other t. <br /> Number of living units: Number of bedrooms ;1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type lMfg - Capacity � No. Compartments <br /> ..-_. <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance:to nearest: Well .Foundation Property Line <br /> . I I � , <br /> h. <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS,. ❑ Depth Size Number <br /> r <br /> SUMPS El Distance to nearest: Well +Foundation Property Line r <br /> .a <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,,and <br /> rules and regulations of the San Joaquin Local Health District. i <br /> Home owner or licensed agent's signature certifies the following: "I cer*that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." ' <br /> The applicant st call for W require P'nspections. Complete drawing on reverse side. <br /> Signed ' Title: <br /> Q-7,��-yt � Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by - Date Area 7 <br /> Pit or Grout Inspection by <br /> Date Final Inspection by ' DateT"���� / <br /> Additional Comments: I <br /> ❑ Stir 466-6781 ❑ Lodi 369-Ml ❑ Manteca 823-7104 ❑ Tracy 8354M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> EX IF <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. i <br /> INFO <br /> +-EH M24(REV.1/s 51' <br /> -ten 7 7`� I; <br /> EH 14-28 <br />